75 N. 13TH STREET, SAN JOSE, CA 95112
Citation Number: 070003702
Citation Date: 2/26/2007
Violation Date: 10/17/2006
Class: AA
Penalty: $ 100000.00

Title 22 72311 (a) (1) (A) (3) (B) Nursing Service- General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.

72311(b) (b) All attempts to notify physicians shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending physician or his designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g).

The facility failed to notify the physician and obtain necessary treatment for the resident's low blood sugar when the resident was maintained on NPO (nothing by mouth); failed to notify the physician when the resident exhibited sudden and adverse changes in behavior such as apprehension, irritability, yelling, and short temperedness.

The facility failed to assess the resident's need when he yelled for help and asked that an ambulance be called, and failed to assess for signs and symptoms of hypoglycemia.

The facility failed to identify the ensuing crisis resulting from low blood sugar levels, and failed to provide the resident emergency care when he became non-responsive.

The facility failed to follow the resident's wishes according to the Preferred Intensity of Treatment, and failed to provide prompt medical and emergency care resulting in the resident's rapid decline and eventual death.

Resident 1 was a 67 year old male readmitted to the facility on 10/07/06 from the acute care hospital. His diagnoses included respiratory failure, chronic renal failure, diabetes, hypertension, atrial fibrillation (rapid, irregular heart rhythm), anemia, left below the knee amputation, and cardiac pacemaker placement.

During medical record review on 2/05/07, the Minimum Data Set (MDS) dated 10/07/06 was not completed and did not have baseline assessment information regarding the resident. The Admission Nursing Assessment dated 10/07/06 described the resident's communication as clear and he spoke English. The resident's psychosocial function was described as alert, friendly, readily answered questions and oriented. His comprehension was also described as "quick". His hearing and vision were adequate. He was described as independent with eating, but needed assistance with bathing, oral hygiene and general grooming. The Interdisciplinary Progress note dated 10/09/06 written by the social service staff described Resident 1 as alert and oriented.

The resident's Preferred Intensity of Treatment (PIT) dated 10/07/06 requested no CPR (no cardio-pulmonary resuscitation) but documented the resident wanted hospitalization, intravenous fluids, enteral feeding and antibiotic treatment.

The physician orders dated 10/07/06 included: Oxygen 2 liters per nasal cannula; dialysis to be done on Monday, Wednesday and Friday; finger stick before every meal and at bed time. The sliding scale order for insulin instructed staff to give orange juice if the resident's finger stick result (blood sugar level) was "0-80".

A review of the Nurse's Progress note dated 10/16/06 documented the resident returned from dialysis. He was alert and in no distress with oxygen at 2 liters/minute per nasal cannula. His oxygen saturation was at 95%. The resident stated to the licensed nurse his AV shunt was plugged and dialysis would be calling the facility with time of repair. The facility staff took an order on 10/16/06 at 4:00 p.m. for the resident's appointment at the acute care hospital the next day (10/17/06) at 1:30 p.m. The resident was to remain NPO (nothing by mouth) after midnight.

A Nurse's note dated 10/17/06 at 4:30 a.m., documented the resident had no acute respiratory distress, denied pain and had no signs/symptoms of hyper/hypoglycemia. Vital signs were BP (blood pressure) 130/80, temperature 97.8, pulse 74, and respiration 20.

On 10/17/06, the Finger Stick Blood Sugar (FSBS) monitoring sheet documented the resident's FSBS at 6:30 a.m. was "62 mg/dl". "NPO" was written under insulin given. The resident's care plan goal dated 10/7/06 for diabetes was to have no signs/symptoms of hypo/hyperglycemia. The interventions included monitoring for signs and symptoms (S/S) of hypoglycemia and if S/S were present, to check the resident's blood glucose and notify the physician prn (as needed).

The facility's Policy and Procedure for Hypoglycemia stated, "If the resident has a blood sugar <60mg/dl with symptoms of hypoglycemia which include: anxiety, pallor, irritability, sweating or mental dullness, the nurse should notify the physician, family, and give one of the following if resident able to take po (by mouth). A. 1 tube of instant glucose orally B. 120cc of orange juice (no additional sugar). C. 120cc cranberry juice or apple juice. D. 2 packets of sugar mixed with 4 oz. of H2O".

There was no documentation the attending physician was notified of the resident's low blood sugar level and the fact he was kept NPO.

One hour later, the Nurse's notes dated 10/17/06 at 7:30 a.m. described the resident as alert and responsive but apprehensive and irritable and yelling out, "help me, help me get up out of bed, let me sit up please." The Nurse's notes further stated "Resident set up and made comfortable. Resident looks haggard, eyes barely open and short tempered. "Resident kept saying, 'call an ambulance, call an ambulance'..." The note continued that reality orientation was provided and staff explained to the resident that his doctor's appointment would be at 1 p.m. The resident replied, "I was not able to sleep last night"

There was no documentation of staff assessment of Resident 1's significant change in behavior, call for help, and request for an ambulance.

On 2/05/07 an interview was conducted with LVN 2, the nurse who took care of Resident 1 on 10/17/06. LVN 2 stated when asked if she thought the resident was showing a change in condition when he asked for help and an ambulance at 7:30 a.m., LVN 2 responded she felt the resident wanted the ambulance to pick him up for his doctor's appointment at 1:30 p.m. She reoriented him thinking he might be confused.

At 10:30 a.m., the Nurse's note documented the resident continued on oxygen at 2L/minute, his oxygen saturation was 94%, blood pressure was 140/80, temperature was 97.4, pulse 70, and respiration 19. His lung sounds were hoarse with no crackles, no wheezing. His abdomen was soft, non tender, and distended. The note continued "In bed still asleep soundly."

There was no documentation of staff assessment or monitoring of Resident 1 for signs and symptoms of hypoglycemia.

During review of the Finger Stick Blood Sugar monitoring sheet at 11:30 a.m. on 10/17/06, it documented the resident's FSBS was "63 mg/dl". Nothing was written for treatment.

The facility did not have a documented assessment of the resident for signs and symptoms of hypoglycemia. There was no notification of the physician of the resident's low blood sugar and the fact the resident was "NPO".

The Nurse's note documented at 12:10 p.m., the resident was nonresponsive. His finger stick blood sugar was checked, 53 mg/dl, oral gel glucagon was given and the resident started licking with his tongue. "Call place to MD spoke to J... for (physician's name) with order for Glucagon one mg (milligram) IM (intramuscular) "STAT" (immediately). The resident remained unresponsive with oxygen saturation at 88%. Staff increased the oxygen to 5L/ minute.

The facility's Policy and Procedure for Hypoglycemia stated, "For residents who are NPO or uncertain of swallowing reflex or if not conscious, give one of the following as ordered: A. Glucagon 1mg IM or SQ or start IV D5W TKO or give 12.5cc Dextrose 50% IV push. Recheck the blood glucose after 10-15 minutes, if blood glucose remains <80 mg/dl, stay and observe the resident, contact the physician for further orders."

Resident 1's FSBS result was 62 mg/dl at 6:30 a.m., and 63 mg/dl at 11:30 a.m. However, there was no documentation the facility contacted the physician, gave the necessary treatment, or rechecked the resident's FSBS every 10-15 minutes as required in their own Policy and Procedure for hypoglycemia.

At 12:20 p.m., the Nurse's note documented the resident "Remained unresponsive - marked pallor noted skin cold and clammy. Nail beds & mucous memb (membranes) with pale grayish in color - gasping for breath - Cheyne Stoke respiration noted."

At 12:40 p.m., the note documented, "Vital signs not appreciated."

At 12:50 p.m. the final Nurse's note, "Call place to MD (doctor). Made update of resident passing away."

LVN 2, when asked what she did when the resident was found unresponsive, stated she checked the FSBS which was 53 mg/dl. She gave the resident an oral Glucagon gel, but when the resident remained unresponsive, she called the attending physician for an order. However, she did not recheck the resident's FSBS or attempt to get the resident's vital signs. LVN 2 stated she increased the resident's oxygen to 5 liters/minute. She stated she did not dial 911.

During an interview on 2/6/07 at 2:20 p.m. with LVN 3, she stated right after her lunch she walked in the resident's room and saw LVN 2 attempting to give Resident 1 orange juice but the resident was not swallowing it. LVN 3 tried to give the oral glucagon to the resident who licked but did not swallow. LVN 2 asked LVN 3 later at the nurse's station to check the resident's Preferred Intensity of Treatment. LVN 3 stated she told LVN 2 the resident had "No CPR" but answered "Yes" to hospitalization. LVN 3 stated she heard LVN 2 state, "I think we need to call 911". When asked why she did not call 911, LVN 3 stated "both phones were busy and (name of CNA) came out of the room and told her "I think he is gone."

In further interview with LVN 2 on 2/6/07 at 1:30 p.m., she stated she felt it was an emergency when she found the resident unresponsive. She stated she wanted LVN 3 to call 911. However, LVN 3 told her "No need to call 911. It's okay give the Glucagon". When asked if the resident exhibited signs of hypoglycemia, LVN 2 stated "yes...". "I should have dialed 911."

During an interview with the Director of Nursing on 2/6/07 at 3:00 p.m., she stated, "I would expect staff to call the doctor for low blood sugars like the residents."

The facility failed to assess the resident's signs and symptoms of hypoglycemia, and failed to identify the increased risk of persistent low blood sugar levels when the resident was NPO. Without obtaining prompt medical treatment, the facility failed to identify the emergent situation that would result due to low blood sugar levels. The facility failed to notify the physician of the resident's documented wish to be hospitalized and honor his Preferred Intensity of Treatment. The facility failed to provide prompt medical and emergency treatment when the resident became non-responsive, leading to his eventual death.

These violations presented either an imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of the death of the resident.